Bacterial and fungal

corneal ulcer/ Suppurative

keratitis

Dr. S. K. Mittal
Prof. and Head
Dept. Of Ophthalmology
AIIMS, Rishikesh
[MBBS Lecture dated 06-02-2018]
•Keratitis-Inflammation of cornea

•Corneal ulcer- Loss of corneal

epithelium with inflammation of
surrounding tissue and stroma and
suppuration, with or without
hypopyon
CORNEAL ULCER

One the common cause of blindness

Included in National Programme for

Control of Blindness
 Classification of Keratitis Bacterial

A] Superficial Infective
l Fungal

Non-infective Viral

Central
Peripheral Acanthamoebal

B] Deep Keratitis
Causative Organisms
Infections are almost always exogenous

Causative organism
• (BACTERIAL):
S. aureus, S. epidermidis, S. pneumoniae,
Pseudomonas aeruginosa.
Uncommon: Neisseria gonorrhoeae, E. Coli

• FUNGAL : Aspergillus and Fusarium sp.(most

common), Candida sp
Predisposing factors

• Trauma: e.g. Contact lenses, trichiasis, surgery

(in fungal typical history of trauma with vegetable

matter, mostly in harvesting season)

• Topical steroids

• Lagophthalmos : e.g. Facial nerve palsy

Predisposing factors

• Neurotrophic keratitis resulting from viral

infections and lesions of ophthalmic division of
Trigeminal nerve
• Dry eye syndrome
• Deficiency states ( Vit. A ) and metabolic diseases
( DM)
• Poor local hygiene and local infection ( chronic
dacryocystitis)
Pathophysiology of ulcer

Progressive • Lymphocytes infiltrates in epithelium

infiltration • Necrosis

Active • Greyish infiltration with circumcorneal

hyperaemia
ulceration • Hypopyon and descemetocele

• Phagocytosis
Regression • Ulcers begin to heal

• Epithelium covers the ulcers

Cicatrization • Scars and opacities formation
Stages of corneal ulcer
Assessment of Corneal ulcer

• History, general, and systemic examination

• Visual acuity: may be low

• Eye and Ocular adnexa: Eye lid , lacrimal sac

• Conjunctiva: circumcorneal congestion, chemosis

• Corneal ulcer: size, site ,surface, margin, slough, corneal sensation,

thinning , satellite lesions

• Anterior chamber: Cells, flare, hypopyon

• Pupil
 Clinical Features of Corneal ulcer
SYMPTOMS:
1. Pain/Foreign body
sensation
2. photophobia
3. DV/Blurred vision
4. Discharge/Watering
5. Redness
6. White spot on Cornea
Clinical Features of Corneal ulcer

Signs:
1. Bleparospasm
2. Lid edema
3. Ciliary congestion of
conjunctiva
4. Ulcer with greyish-
white necrotic slough
5. Hypopyon+-
Symptoms in Mycotic Corneal Ulcer
are less prominent than an equal
size Bacterial ulcer
 signs
SIGNS BACTERIAL FUNGAL
Lids Swelling of lids Might be present
Blepharospasm present present
Conjunctival chemosis Present+++ Present++
and hyperemia
Ciliary congestion +++ +++
Ulcer Greyish-white Elevated rolled out
circumscribed infiltrate, margins
Yellowish-white oval/ Satellite lesion
irregular area of ulcer. Dense suppuration
Stromal edema Endothelial palque
Hypopyon Hypopyon Hypopyon(infected,imm
(sterile, whitish, mobile obile,yellowish),
common
Complications Corneal perforation Endophthalmitis
,endophthalmitis
Symptoms are less as compared to signs

FUNGAL CORNEAL ULCER

Differential Diagnosis of ulcer

• Acute conjunctivitis
• Acute iridocyclitis
• Acute congestive glaucoma
• Corneal Opacity
Complications of Corneal Ulcer

I. Descematocele
II. Perforation and its complications : Anterior synechia , Iris
prolapse, expulsion of lens and vitreous, Intraocular hemorrhage,

iii. Endophthalmitis / panophthalmitis

iv. Secondary glaucoma

v. Anterior capsular cataract

vi. Staphyloma formation

VII. Corneal opacity
 Microbiological Investigations
• The majority are managed without smears or cultures.

• Scraping done: from ulcer margins and base of ulcer

• Examination of Smear stained with Gram stain, Giemsa stain,

KOH mount for fungi.

• Culture on blood agar, chocolate agar, thioglycollate broth, and

Sabouraud’s dextrose agar
Management

Principles:
• Control of infection
• Symptomatic relief
• Prevention of complications
Control of Infection(for bacterial ulcer)

• Topical antibiotics
Fluoroquinolone eye drop:
• Cipro/ ofloxacin
• moxifloxacin(0.5%) drop.
• Gatifloxacin 0.3 % drop.

Alternatives

• Fortified cephazolin eye drop

• Fortified tobramycin eye drop
• Fortified vancomycin eye drop
Antimicrobials for Fungal corneal ulcer

• Topical antifungal drops:

• - Natamycin 5 % 1 hourly by day and 2 hourly by night for 6 weeks to 6

months

• - Amphotericin B 0.15/ 0.3 % frequent instillation

• Oral antifungal agents; Ketoconazole 200-600 mg/ day .Fluconazole 200-

400mg/ day

• Scrapping done to help removal of slough and penetration of the drug

• Along with antibiotics support to prevent secondary bacterial infections

Treatment

• Cycloplegics : Atropine 1 % eye drop t.i.d.

• Hot fomentation
• Systemic analgesics : Anti-inflammatory drugs
such as paracetamol & ibuprofen

• Removal of local predisposing factor

• Vitamins ( A, B-complex & C)

Treatment ( Non Healing Corneal Ulcer)

• Debridement of ulcer

• Chemical Cuterization

• Cyano acrylate glue

• Therapeutic penetrating keratoplasty

• Treatment of complications: perforation,

secondary glaucoma
Outcome of corneal ulcer

• Healing with out opacity

• Healing with opacity
• Staphyloma
• Secondary glaucoma
• Cataract
• Phthisis bulbi
Source
 Text-Kanski, Parson’s, Samar Basak, Pradeep
Sharma
 Photographs- above , Archives & Website